A Vision for Midwifery in the United Statesby Ina May Gaskin

As anyone who has read Spiritual Midwifery knows, the development of my vision for midwifery in my community was a rather quick process. I knew what I needed, and I knew what my friends wanted and needed. Together, we worked to access the kind of external help we required to learn how to provide dependable, skilled care for the women in our community (and later for others) during pregnancy, birth and the newborn period. Our realization of that original vision has existed virtually unchanged for more than 30 years.

The development of my vision of midwifery for the entire United States has been a far more gradual process. Envisioning a system of midwifery to serve a population of 280 million people is far more complicated than envisioning a system to serve 1500 people who know each other quite well and who share both a lifestyle and a view that birth should, whenever possible, take place at home.

At the same time, there are similarities between microcosm and macrocosm. We at The Farm had to establish an educational program that included both didactic and practical clinical elements. We had to develop standards, protocols and definitions that helped us and women in our community to distinguish between the student midwife and the midwife who had attained the skills, knowledge and experience to provide care that is her own responsibility. We had to establish working relationships with medical professionals and the Tennessee Department of Health and Environment, and within our own circle, we had to deal with work overload and burnout. In a very real sense, we did not function as individuals, but rather as members of a group that shared a common vision and, therefore, common goals. I’m very clear about the need for collective action on the part of midwives if we are to realize any vision of midwifery that can survive into the future.

All midwives should have the opportunity for clinical experience in the settings in which they will practice.

Midwifery was destroyed a century ago—in large part, because US midwives had not organized and established midwifery as a profession. The anti-midwife propaganda campaign carried out by organized medicine was not countered by any collective argument from midwives. This is why medicine was able to destroy midwifery with so little expense and effort. Even though there were tens of thousands of midwives at the time, their lack of state or national organizations and the lack of midwifery schools meant that when each of the midwives died, there was no one to replace her. Young women no longer saw midwifery as a possible career. Women who themselves had been born at home went to hospitals to give birth, despite the fact that in those pre-antibiotic days maternal death rates were higher in hospitals than at home. In our own times, a majority of US women are as ill-informed about the respective advantages of midwifery and obstetrics and the capacities of their own bodies as were their foremothers nearly a century ago.

Despite this disadvantage, midwifery now has a second chance at re-establishing itself in a stronger way than the midwives of the early 20th century were able to envision. I believe strengthening midwifery for the future will require us to overcome our fears surrounding professionalization. Without professionalization, there would be no hospital-based midwifery care at all. If we want midwives to be available for our grandchildren and their children, we midwives will have to commit to high professional standards, to creating reliable mechanisms by which one can make a living at midwifery and to being accountable to women for our practices. We will also have to accept responsibility to refer pregnant or laboring women to medical providers when we reach the limit of our expertise. Our goal should be autonomous practice regardless of setting. I would like to see a midwifery practice that is accountable to women and their needs, rather than to corporate needs or to the requirements of other professions.

To those who believe gaining professional status means a necessary loss of autonomy, I would say the autonomy some homebirth midwives have now is extremely fragile in those states that have not yet legitimized the practice of direct entry midwifery. Many midwives are still one fetal death away from discipline, not by their professional colleagues, but rather by the criminal justice system. And when these midwives reach the end of their working years, there are not likely to be replacements for them unless we who are midwives now create the foundations for the future of midwifery. Individuals, regardless of talent and competence, cannot erect such foundations. It must be a cooperative effort.

In the event that the United States establishes health care as a right for all of its citizens (as it should), every woman should be able to have a midwife as her maternity care provider if she so chooses. We are likely to find that a reduction in the number of obstetricians produced each year will not come until a national health insurance program is established. Only then will we find a national incentive to adjust the ratio of obstetricians to midwives in a way that is rational and beneficial to birthing women. Midwives need to become part of the system so that when health care reform comes, we will be seen as a necessary component of the system.

I believe the ideal midwifery system is founded upon the partnership between midwives and the women they serve. In such a system, midwives create ways to be directly accountable to both their colleagues and to the women they serve. New Zealand midwives are leading the way in establishing such systems through the creation of their Midwifery Standards Review Process. Their voluntary review process is nationally and regionally coordinated by midwives and women who evaluate the quality of independent midwifery practice according to nationally accepted standards for practice. Both professional colleagues and consumers make up the review teams, which helps to provide a buffer against the tendency to evaluate the practice of midwives according to the standards of another profession (such as obstetrics).

As for midwifery education, I would like to see an expansion of midwifery schools until each of the more heavily populated states has one, with less populated states cooperating within their areas to educate prospective midwives. All midwives should have the opportunity for clinical experience in the settings in which they will practice.

In our campaign to resurrect a destroyed profession in each of our countries, we North American midwives are attempting to do what has never been done before. It seems Canadian-registered midwives, working within a national health system, have met fewer barriers to practice than have US midwives who have won the right to practice midwifery. I believe it is still too early to know whether Canadian midwives will be able to achieve the degree of autonomy of practice that their New Zealand colleagues have won, but we should recognize that the Canadian process is still in its infancy.

Some things are quite clear at this point: First, midwifery will continue to change and to meet both internal and external challenges. Second, no great vision can be attained without sacrifice and effort. Finally, midwives and women, working in partnership, can be a powerful force in creating social change. We will never know what we might accomplish unless we try.

Ina May Gaskin, MA, CPM, is founder and director of the Farm Midwifery Center (est. 1976) located near Summertown, Tennessee. By 1996, the Farm Midwifery Center was handling more than 2,200 births, with remarkably good outcomes. Ms. Gaskin herself has attended more than 1,200 births. She is author of Spiritual Midwifery, Babies, Breastfeeding and Bonding, and has lectured all over the world at midwifery conferences and at medical schools, both to students and to faculty. She is currently president of Midwives’ Alliance of North America. Her promotion of a low-intervention but extremely effective method for dealing with one of the most-feared birth complications, shoulder dystocia, has resulted in that method being adopted by a growing number of practitioners. The Gaskin Maneuver is the first obstetrical procedure to be named for a midwife. She was featured in Salon magazine’s “Brilliant Careers” in the June 1, 1999, edition. (http://www.salon.com/people/bc/1999/06/01/gaskin).